Indirect post-implant lesions of the inferior alveolar nerve. Radiological and biomechanical findings.

THE AIM OF THE WORK.: The mandibular canal, if it is affected by different illnesses, often shows typical radiological changes, made up of widespread hypodensity, an increase in its diameter and disappearing walls. This study aims to verify the reliability of such radiological signs in the cases of later post-operative lesions of the mandiblular canal. MATERIALS AND METHOD.: The study includes 16 patients, 9 males and 7 females, with an average age of 54 years, who underwent an operation to rehabilitate the mandible with a prosthetic implant for a total of 37 implants. All the subjects underwent an Orthopantograph due to the appearance of painful radicular symptoms some time after the operation. RESULTS.: In 36 cases out of 37 we found, with the Orthopantograph, a slight increase in the calibre of the mandibular canal compared to the controlateral. In 10 subjects we observed hypodensity of the canal itself, while in 6 subjects the canal passages were no longer recognisable. CONCLUSION.: The radiological indications of damage of the inferior alveolar nerve (IAN) are reliable even in the case of indirect post-implant lesions.

[Diagnostic imaging of current pulmonary tuberculosis. Clinical significance of the presentation patterns and particular aspects in HIV-positive and HIV-negative subjects]. / Diagnostica per immagini della tubercolosi polmonare attuale. Significato clinico dei quadri di presentazione e aspetti particolari nei soggetti HIV positivi e HIV negativi.

PURPOSE: We compared two groups of risk patients to try to identify different radiologic patterns in pulmonary tuberculosis. MATERIALS AND METHODS: 74 subjects, divided into two groups (HIV+:27; HIV-:47) were included since 1993. The patients were examined with chest X-ray (CXR) and CT. RESULTS: In the HIV+ group we observed 40 radiologic alterations, with 6 cases of bilateral lung involvement and 9 of atypical localizations; particularly: 11 consolidations, 8 cavitations, 5 miliary diseases, 9 hilar or mediastinal adenopathies, 3 extrapulmonary localizations and 4 negative CXRs. In the HIV- group we found 53 radiologic alterations, with 6 cases of bilateral lung involvement and 3 of atypical localizations; particularly: 12 consolidations, 25 cavitations, 5 nodular patterns, 1 miliary disease, 5 nodal disease, 4 pleural diseases and 1 negative CRX. DISCUSSION AND CONCLUSIONS: In HIV- patients lung consolidations and tysiogen patterns are significantly prevalent, while miliary diseases, mediastinal diseases and atypical localizations and negative CRXs are more frequent in HIV+ patients. We found miliary diseases, mediastinal diseases and extrapulmonary localizations also in HIV- patients with heavily impaired social, economic and sanitary conditions. This alterations indicate compromised host resistance, independent of the causes and modalities of immunodeficiency. The distinction between primary and secondary tuberculosis is currently not mandatory.

[Lung tuberculosis in HIV positive patients. Clinico-radiologic correlations]. / La tubercolosi polmonare nei pazienti HIV positivi. Correlazioni clinico-radiologiche.

UNLABELLED: We investigated the radiologic features of pulmonary tuberculosis in HIV+ patients. SUBJECTS AND METHODS: 24 cases of pulmonary tuberculosis in HIV+ patients were studied (17 men and 7 women, average age: 38 years). The study includes 19 drug addicts, 3 homosexuals, 1 polytransfused subject and 1 patient not belonging to the categories considered at risk). Three subgroups were identified by the CD4/mm3 cell count (< 200, 200-500, > 500). RESULTS: In our 24 patients, we identified 37 radiologic manifestations (in 13 cases associated in the same patient), with 6 cases of bilateral pulmonary and 9 atypical localizations. In detail: 10 consolidations, 7 productive (miliary) cavitations, 8 mediastinal lymphadenitis, 3 extrapulmonary forms and 4 cases with no chest X-ray alterations. There is a major frequency of consolidations and cavitations in the patients with CD4 > 200 and a major frequency of productive forms, lymphadenitis and extrapulmonary localizations in the subjects with CD4 < 200. We observed no cases of tuberculosis in patients with CD4 > 500. The medical therapy is usually more effective in the more immunocompetent subjects and, anyway, in the exudative forms, improving in 35% of cases, than in the productive and disseminated forms improving in 6% of cases only. DISCUSSION AND CONCLUSIONS: Only the severely immunodeficient HIV+ patients (CD4 < 500) are affected with tuberculosis. There exists a significant rate of parenchymal consolidations and tisiogenic forms in subjects with CD4 > 200 and a high rate of miliary forms, lymphadenitis and extrapulmonary localizations in patients with low cell count (< 200). The medical therapy is more effective in the more immunocompetent subjects and, anyway, in the exudative forms, than in the productive and disseminated forms. Finally, atypical localization of pulmonary tuberculosis are frequent in HIV patients.

Comparison of dobutamine stress echocardiography with dipyridamole stress echocardiography for detection of viable myocardium after myocardial infarction treated with thrombolysis.

OBJECTIVE: To compare the ability of dobutamine and dipyridamole stress echocardiography to detect functional recovery of stunned but viable myocardial regions early after acute myocardial infarction, and to predict late functional recovery of the reperfusion salvaged myocardium within the infarct area. METHODS: Within 10 d of acute myocardial infarction, 51 patients--30 anterior and 21 inferior, 44 Q wave and seven non-Q-wave infarction--were submitted to a dobutamine echocardiography test at low dose (5-10 micrograms/kg/min over 5 min) and high dose (20-40 micrograms/kg/min over 3 min) and to dipyridamole echocardiography test (0.56 mg/kg over 4 min + 0.28 mg/kg over 2 min) on different days and in random order, after interruption of any vasoactive drug. Resting echocardiography was repeated at two months in 41 of 51 patients (80%). Regional wall motion of the left ventricle was analysed in a semiquantitative manner on a 14-segment model. Viability was defined as improvement of one grade or more of at least two basally asynergic segments in the infarcted area. RESULTS: Regional functional recovery was detected by low dose dobutamine in 38/51 patients (75%) and in 147/308 (48%) of basally asynergic segments, compared to 25/51 patients (49%; P < 0.001) and 78/308 segments (25%; P < 0.001) only identified by dipyridamole. Late spontaneous functional recovery was detected in 24/41 patients (59%) and in 78/254 basally asynergic segments (31%). The sensitivity of dobutamine and dipyridamole echocardiography for predicting spontaneous functional recovery was 72% and 51% respectively (P < 0.001), specificity 68% and 82% (P < 0.001), positive predictive value 50% and 56%, and negative predictive value 85% and 79%. CONCLUSIONS: In comparison with dipyridamole in patients with thrombolysed myocardial infarction, dobutamine induces regional functional recovery. This suggests that dobutamine is more sensitive in showing the presence of viable myocardium within the infarct zone, though it has a lower specificity in predicting delayed spontaneous functional recovery of non-contractile but still viable areas.

Syncope caused by cardiac asystole during dobutamine stress echocardiography.

Syncope caused by cardiac asystole during dobutamine stress echocardiography occurred in a 60 year old woman presenting with chest pain and a non-diagnostic exercise test. Cardiac asystole was not associated with myocardial ischemia and was attributed to a powerful cardioinhibitory vagal reflex elicited by the stimulation by the drug of cardiac and aortic mechanoreceptors. Cardiac asystole was promptly reversed by the administration of atropine with no significant sequelae.

Results of dipyridamole plus atropine echo stress test for the diagnosis of coronary artery disease.

Sensitivity of dipyridamole stress echocardiography (DIP-E) has been reported to be less than ideal in particular subsets of patients such as those with less severe extent of coronary artery disease (CAD). To verify if sensitivity could be improved, ATRO (1 mg in 2 minutes) was added at the end of a negative high-dose (0.84 mg/kg over 10 minutes) DIP-E in 61 consecutive patients (58 men, aged 53 +/- 7 years) evaluated for chest pain (33%) or for detection of residual ischemia after acute myocardial infarction (AMI) or previous MI (67%). DIP-E was positive in 28/61 (46%) and negative in 33/61 (54%) patients. Additional echo positivity was obtained in 18/33 (54%) patients after ATRO. Coronary arteriography was normal in 6 patients (10%); 1-vessel CAD was diagnosed in 28 (46%), 2-vessel CAD in 16 (26%) and 3-vessel CAD in 11 (18%) cases. The sensitivity for CAD diagnosis was 49% (27/55) for DIP-E and 84% (46/55) for DIP-E+ATRO (p < 0.001). Specificity was 83% and 80%, respectively. Diagnostic accuracy increased from 52% to 83% (p < 0.001). The better diagnostic accuracy of DIP-E was mainly related to the significant increase in sensitivity of the combined test in patients with 1-vessel CAD (from 46% to 75%) (p < 0.005). At quantitative coronary evaluation, compared to patients with positive DIP-E+ATRO or negative DIP-E+ATRO test, patients with positive DIP-E had a higher mean % diameter stenosis: 80 +/- 13% vs 72 +/- 24% and 65 +/- 36%, respectively. Peak heart rate was significantly higher after the addition of ATRO vs basal and DIP alone in patients with a positive DIP-E+ATRO test. The addition of ATRO to DIP increases diagnostic accuracy of DIP-E particularly in patients with less severe extent of CAD; ATRO may be considered as a useful routine procedure for increasing diagnostic value of DIP-E test.

Activation of the hemostatic mechanism during thrombolysis in patients with unstable angina pectoris.

In patients with myocardial infarction, thrombolytic therapy induces a paradoxical activation of the hemostatic mechanism. In patients with unstable angina, the effect of thrombolysis on the coagulation cascade is unknown. We prospectively measured the plasma concentrations of prothrombin fragment 1 + 2 and fibrinopeptide A in consecutive patients with unstable angina randomized to receive placebo alone (n = 23), streptokinase 1,500,000 IU over 1 hour followed by a 48-hour placebo infusion (n = 21), or streptokinase 250,000 over 1 hour followed by a continuous infusion of 100,000 IU per hour over 48 hours (n = 20). All the patients received intravenous heparin for 72 hours. The plasma levels of the different markers were measured at baseline, 90 minutes, 24 hours, and 48 hours after the start of therapy. The median baseline plasma concentrations of prothrombin fragment 1 + 2 and fibrinopeptide A were similar in the three treatment groups. In comparison with placebo, an increase in plasma prothrombin fragment 1 + 2 and fibrinopeptide A, was observed after 90 minutes in the two groups receiving thrombolysis. After 24 and 48 hours, the prothrombin fragment 1 + 2 levels remained significantly higher only in the patients receiving the 48-hour streptokinase infusion. In patients with unstable angina, thrombolytic therapy induces an activation of the hemostatic mechanism, despite concomitant heparin administration; in those receiving a prolonged streptokinase infusion, the activation of coagulation persists for as long as the drug is administered.

[The side effects and safety of the echo-dobutamine test. The experience with 373 patients]. / Effetti collaterali e sicurezza del test eco-dobutamina. Esperienza in 373 pazienti.

BACKGROUND: A potential limitation to the clinical utilization of dobutamine stress echocardiography is the higher incidence of side effects in respect to other noninvasive tests for the diagnosis of coronary artery disease reported by some authors. Due to the increased utilization of this test for the evaluation of chest pain and for prognostic stratification in patients with a recent myocardial infarction, we analyzed the results of 373 consecutive tests to evaluate the incidence and clinical significance of side effects induced by dobutamine. METHODS: Dobutamine stress echocardiography was performed in 256 patients (69%) for the evaluation of chest pain; 85 out of 256 (33%) suffered from a previous myocardial infarction. 117 patients (31%) were studied in the early phase after an acute myocardial infarction for prognostic purposes. Dobutamine was infused starting with the dose of 5 gamma/kg/min over 3 minutes with incremental steps of 10-20-30-40 gamma/kg/min over 3 minutes under 2D-echocardiographic and 12-lead electrocardiographic monitoring. RESULTS: In 95% of cases the test was stopped at the achievement of a target end point: wall motion abnormalities (60%), significant ECG changes (5%), 85% of the age-predicted maximal heart rate (13%), maximal dose (17%); only in 5% of cases a limiting side effect requiring a premature interruption of the test occurred: hypertension (systolic blood pressure over 240 mm Hg and/or diastolic over 120 mm Hg) (2%); symptomatic hypotension (0.5%); severe chest pain (1%); nausea (0.5%); cardiac arrhythmias (1%). Cardiac arrhythmias were the most frequently registered non limiting side effect. During the test 79 episodes of supraventricular arrhythmias and 211 episodes of ventricular arrhythmias occurred. Supraventricular arrhythmias consisted usually of benign sporadic premature beats; only 3 cases of self-limiting supraventricular tachycardia or atrial fibrillation were recorded. Sporadic ventricular premature beats were the most frequently recorded arrhythmias; 10 patients developed a ventricular tachycardia; however in no case this arrhythmia was sustained, associated with subjective symptoms and required the administration of a specific antiarrhythmic drug or the premature interruption of the test. Patients were divided according to the absence (Group 1, G1, n = 193, 52%) or the presence (Group 2, G2, n = 180, 48%) of cardiac arrhythmias during the test. Patients of G2 differed from patients of G1 only in respect of the maximal dose of dobutamine infused (33.5 vs 28.6 gamma/kg/min, p < 0.0005) and the incidence of a wall motion abnormality in the basal echocardiogram (66% vs 53%, p < .01). The second most recorded non limiting side effect (71/373 pts) (19%) was the occurrence of systolic hypotension, a drop of systolic blood pressure > or = 20 mm Hg in respect of the antecedent infusion step. In all cases no symptoms developed and the great majority of patients with this finding had a normal echocardiographic response to dobutamine at the time of his occurrence. CONCLUSIONS: Dobutamine echo stress test is limited by the occurrence of significant side effects only in a minority of patients (5%); however in all cases, including complex ventricular arrhythmias, these side effects were self limiting and promptly recovered after interruption of the drug infusion. Non limiting side effects, in particular cardiac arrhythmias and systolic hypotension, are usually well tolerated and not associated with the occurrence of myocardial ischemia or left ventricular disfunction; thus, dobutamine echo stress test may be considered a safe test for the evaluation of the presence and severity of coronary artery disease both in patients with a previous or recent myocardial infarction and in patients without myocardial infarction.

Haemodynamic effects of glyceryl trinitrate during continuous 24 hour infusion in patients with heart failure.

OBJECTIVE: To investigate whether the susceptibility to tolerance to glyceryl trinitrate is similar in different vascular beds in patients with chronic heart failure. PATIENTS: Twenty patients with heart failure underwent a continuous infusion of glyceryl trinitrate over 24 hours followed by administration of N-acetylcysteine (5 g intravenously) in a bolus. MAIN OUTCOME MEASURES: Haemodynamic measurements under control conditions, at peak titration of glyceryl trinitrate at 24 hours, and after N-acetylcysteine; plasma renin activity and packed cell volume. RESULTS: After 24 hours of infusion the acute reduction in right atrial pressure had largely waned, while pulmonary vascular resistance remained improved and systemic resistance, which was not reduced at peak titration, significantly decreased with respect to control conditions. The effects of N-acetylcysteine and hormonal responses were different in patients who did and did not develop tolerance to glyceryl trinitrate. CONCLUSIONS: The haemodynamic profile of glyceryl trinitrate changed substantially during the study from a predominantly venodilator action at peak titration to a predominantly arteriolar dilatation after 24 hours of infusion. The different effects of N-acetylcysteine and the different hormonal responses confirm the multifactorial pathogenesis of tolerance to glyceryl trinitrate.

Hemodynamics of volume loading compared with dobutamine in severe right ventricular infarction.

To compare the hemodynamic effect of volume loading with that of dobutamine infusion in severe ischemic right ventricular (RV) dysfunction, 11 patients with inferior and RV infarction complicated by low cardiac output syndrome and important hemodynamic derangement (systolic blood pressure < 100 mm Hg, cardiac index < 2.0 liters/min/m2, right atrial pressure > 10 mm Hg) were prospectively studied within 48 hours of symptom onset. After right heart catheterization, volume loading (mean 400 ml saline solution) and dobutamine infusion (5 and 10 micrograms/kg/min over 10 minutes) were performed according to a randomized, crossover design. Volume loading resulted in increased right atrial (from 15 +/- 2 to 19 +/- 3 mm Hg, p < 0.05) and pulmonary capillary (from 15 +/- 2 to 19 +/- 3 mm Hg, p < 0.05) pressures, without increasing cardiac index, heart rate, aortic pressure, or right and left ventricular stroke work index. Dobutamine (5 micrograms/kg/min) increased cardiac index (from 1.5 +/- 0.3 to 1.9 +/- 0.5 liters/min/m2, p < 0.05), incrementing both heart rate (from 61 +/- 12 to 70 +/- 13 beats/min, p < 0.05) and stroke volume index (from 25 +/- 6 to 27 +/- 5 ml/beat/m2, p < 0.05), as well as right (from 1.4 +/- 1.6 to 2.3 +/- 2.2 g.m/m2, p < 0.05) and left (from 21 +/- 7 to 27 +/- 10 g.m/m2, p < 0.05) stroke work indexes; right and left ventricular filling pressures did not decrease. Dobutamine (10 micrograms/kg/min) significantly improved myocardial performance.(ABSTRACT TRUNCATED AT 250 WORDS)

[The echo-dobutamine and echo-dipyridamole tests in assessing vital myocardium and residual ischemia in myocardial infarct after thrombolysis]. / Il test eco-dobutamina ed eco-dipiridamolo nella valutazione del miocardio vitale e dell'ischemia residua nell'infarto miocardico dopo trombolisi.

The aim of the study was to compare the ability of dobutamine and dipyridamole echocardiography to detect stunned but viable myocardium early after acute myocardial infarction, to predict spontaneous functional recovery of the reperfused myocardium at 2 months and to detect myocardial ischemia in the infarcted area. Within 10 days from acute myocardial infarction, 47 patients, 29 anterior and 18 inferior, 41 Q-wave and 6 non Q-wave infarctions, underwent dobutamine echocardiography test at low-dose (5-10 mcg/kg/min over 5 min) and high-dose (20-40 mgc/kg/min over 3 min) and to dipyridamole echocardiography test (0.56 mg/kg over 4 min + 0.28 mg/kg over 2 min) in different days and in random order, after interruption of any vasoactive drug. Resting echocardiography was repeated at 2 months in 38/47 patients. Regional wall motion analysis was performed in a qualitative manner on a 14-segment model; viability was defined as improvement of 1 grade or more of at least 2 basally asynergic segments in the infarcted area. Ischemia was defined as an improvement followed by significant deterioration of contractility of the infarcted segments or deterioration of the infarcted area. All patients underwent coronary arteriography within 1 month from admission. Viability was detected by low-dose dobutamine in 34/47 patients (72%) and in 131/297 (44%) of basally asynergic segments compared to only 21/47 patients (45%) and in 66/297 segments (22%) detected by dipyridamole; myocardial ischemia was induced by dobutamine in 64% of patients compared to 36% by dipyridamole. Late spontaneous functional recovery was detected in 21/38 patients (57%) and in 70/244 (29%) of asynergic segments. Sensitivity of dobutamine and dipyridamole echocardiography for predicting spontaneous functional recovery was 70% and 46% specificity 69% and 83%, positive predictive value 48% and 52%, negative predictive value 85% and 79% respectively. Dobutamine correctly identified the presence of a significant stenosis of the infarct-related artery in 74% of cases compared with 43% of dipyridamole; specificity for detecting stenosis was 67% for dobutamine and 83% for dipyridamole. In conclusion, in patients with thrombolyzed myocardial infarction dobutamine echocardiography detects viable myocardium with late spontaneous recovery in a greater proportion of patients and segments than dipyridamole; dobutamine has a higher sensitivity but a lower specificity compared to dipyridamole for identifying a residual stenosis of the infarct-related artery that may jeopardize myocardium in the area at risk.

[Double-contrast esophagography in the diagnosis of esophagitis due to Candida. A study on HIV-seropositive patients]. / L'esofagografia a doppio contrasto nella diagnosi di esofagite da Candida. Studio su pazienti sieropositivi per HIV.

This study was aimed at assessing the sensitivity of double-contrast esophagography in diagnosing Candida esophagitis. This condition accounts for 85% of all esophageal infections in the subjects suffering from AIDS. Thirty-nine HIV+ patients were evaluated: 19 of them had endoscopic diagnosis of Candida esophagitis. Our study confirmed the high sensitivity of esophagography (90%), as reported in the literature. Radiographic findings were edematous esophageal folds in the early stage and, subsequently, plaques and diffuse ulcerations. These patterns are suggestive of anatomical lesions: in the early stage, mucosal edema and erythema are observed, and later on pseudomembranes and ulcerations. None of our patients exhibited stenosis. All the subjects with Candida esophagitis had less than 250/mm3 of CD4 lymphocytes. In conclusion, double-contrast esophagography must be included in the periodic examinations performed on patients with AIDS, so as to allow an early diagnosis.

[The echographic visualization of the lingual bolus. The reference point in a study of dysphagia]. / La visualizzazione ecografica del bolo linguale. Punto di riferimento nello studio delle disfagie.

The videotape recording of the cinefluorographic images obtained with barium swallowing, proved to be very useful in studying pharyngo-esophageal motility. On the contrary, the method failed to be exhaustive in the study of the oral phase of swallowing. In 1983 Shawker et al. were the first authors to suggest the use of US to record tongue motility and the upward movement of hyoid bone. In a previous paper the authors had reported on the value of US videorecording in the dynamic study of oral swallowing, and of lingual bolus development and shape. In the present paper, the authors investigated how frequently the formation of lingual bolus can be recorded by means of US in patients with no dysphagic disorders. Sagittal and transverse scans were acquired in all patients with US units with 5 MHz probes connected to a U-matic videorecorder. In 98% of 50 examined patients, US demonstrated the presence of a lingual bolus in the preparatory phase of oral swallowing. Since lingual bolus formation in the oral phase of swallowing can be considered quite a normal event, the authors believe this finding to be a reliable reference-point in the study of oral swallowing.

[Dynamic study of oro-pharyngeal deglutition]. / Lo studio dinamico della deglutizione oro-faringea.

Oropharyngeal swallowing is too fast and complex a motion for the human eye to seize its various phases and subsequently evaluate morphology and function of the anatomical structures involved. A chronological subdivision of the swallowing act is needed for a step-by-step analysis. Dynamic evaluation of oropharyngeal swallowing by means of fluoroscopic and US videorecording proved to be a reliable method. Echovideorecording allowed tongue movements to be depicted, together with bolus formation and propulsion. Fluorovideorecording (U-matic Sony unit, 25-30 images/sec) demonstrated pharyngeal and esophageal phases. A series of chronological and morphological reference points, which characterize oropharyngeal swallowing, were employed to analyze videorecorded images. Slow-motion mode, "freezed" images, and rewinding allowed an easy and accurate evaluation of swallowing details. Combined chronological and morphological pieces of information allow a comprehensive evaluation of the swallowing act.

[Echography of the oral phase of deglutition]. / L'ecografia nello studio della fase orale della deglutizione.

Neither cineradiography nor videorecording are satisfactory techniques for the dynamic study of the oral phase of deglutition. Therefore, oral swallowing was studied by means of real-time sonography (US) in 20 asymptomatic patients. Both anatomy and motility of the muscles of the mouth and tongue were clearly demonstrated. Real-time US proved thus to allow an accurate and dynamic visualization of the oral phase of deglutition.